Mood disorders remain difficult to diagnose

Posted November 29, 2012

By MELISSA CASTILLO
School of Communication
University of Miami

Bipolar disorder was once perceived as black and white.

Either someone had intense mood swings ranging from a state of euphoria to a suicidal mindset or they didn’t, which would disregard a possible mood disorder that was closer to the center of this range. That has now changed with scientific advancement that stretches the spectrum of what constitutes as bipolar disorder.

The concept of milder forms of bipolar disorder is fairly new in comparison to when the relation between mania and melancholia was first established.

While this has been documented since the time of the Romans, milder forms only first began to gain prominence at the turn of the 20th century through the work of renowned psychiatrist Carl Gustav Jung, as mentioned in the e-book Interpersonal Factors in Onset and Course of Affective Disorder by Christoph Mundt and Hugh L. Freeman.

By now, there are three to six universally accepted forms of bipolar disorder. The variations in which bipolar disorders are covered are based on the source one chooses to use. WebMD acknowledges the more well known mild versions of bipolar I disorder, including bipolar II and mixed bipolar. Bipolar II is distinguished by more episodes of depression and never reaching the full on mania that those with bipolar I experience.

Mixed bipolar is exactly what it sounds like, a mix of mania and depression at the same time. Those that suffer from this endure the intensity of elaborate, delusional and racing thoughts found in manic episodes in bipolar I but differ in the sense that they are all intertwined with negativity.

Although the mood changes with bipolar II and mixed bipolar aren’t as drastic as with bipolar I, they both present greater risks of suicide. This is a reason why they must be treated with the same amount of sensitivity as one would with bipolar I. They must not be regarded as intense mood swings, but rather a legitimate mental illness.

“Bipolar disorder differs from typical mood swings in several ways,” said Dr. Amanda Jensen-Doss, assistant professor in the Department of Psychology at the University of Miami. “First, the moods last longer. Specifically for bipolar II disorder, they must have had a hypomanic episode, which is defined as a distinct period of expansive, elevated or irritable mood that lasts throughout the day for at least four days. The moods must then be extreme and accompanied by a variety of other symptoms. Finally, the mood state must cause impairment, meaning that it causes the person problems.”

Yet, there are some people who can’t grasp the validity of less severe forms of bipolar disorder since they don’t always manifest into extreme public outbreaks, as Hollywood sometimes portrays it. A reason why milder forms aren’t always perceived as being anything serious to friends or family is because they lean more towards the depressive side and by nature, depressive moods tend to be more reclusive than manic mentalities and can even be misconstrued as simple irritability.

“I don’t understand this whole idea that if someone is upset they have a mental problem. Everybody deals with emotional instability at some point or another,” said Manuel Santamaria, assistant pathologist at Baptist Hospital. “I constantly have this debate with my niece, who was diagnosed with bipolar type II. When she claims to go through an episode, the way she acts just seems like something she should be able to control.”

A reason why somebody may be out of touch with the seriousness of mental illnesses is because it isn’t portrayed in the way typical medical issues are and therefore it would be easy for someone to come to the conclusion that it is all in the person’s head.

“There’s a good metaphor that can help somebody understand that milder forms of bipolar disorder isn’t just in someone’s head,” said Jennifer Vasilev, 28, who was diagnosed with mixed bipolar disorder in her early 20s. “If your leg is broken, wouldn’t you go to the hospital? If it’s really mind over matter, then just think your leg isn’t broken and you’ll be fine. This is the same with a mental illness. Just because you can’t see it, doesn’t mean it’s not there.”

Criticism from the outside perception can also come from the assumption that seeking medical help and therefore, medication for a mental illness, is an easy way out. Santamaria referred to the medication prescribed to his niece as a “happy pill.”

Often times, people who aren’t aware of how it feels to endure mental instability, don’t understand that somebody diagnosed with a mental disorder isn’t taking medication to be happy. The purpose is to restore their balance so they can handle the world on the same platform as anybody else.

Those with the disorder still experience typical mood swings, but not so much to the point that it disrupts and potentially destroys aspects of their life, as bipolar disorder is known to do if left untreated. According to the National Institute of Mental Health website, it can strain relationships, hinder healthy socializing, lead to an inability to hold a job, an immense amount of debt, substance abuse, hospitalization, panic attacks, and the most life changing possibility, suicide.

“How does it not affect my life?” Vasilev responded when posed with the question. “I can’t think of one way or another it hasn’t. It is all consuming. Even with my medication, I have to deal with it on a regular basis. I’m just lucky to have a caring family.”

It’s unfortunate that it may take a severe circumstance for a close family member to even believe that the mental disorder is a critical internal battle, which was something that Vasilev had to overcome.

“My dad wasn’t always on board about me having a mental illness. Sometimes I think he didn’t even believe me,” she said. “But when I had to be hospitalized for two weeks in March 2010, he finally realized how serious it really is.”

The cause for her hospitalization was because her negative thoughts reached a level of intensity like they never had before and spiraled until she was lost within them.

“I broke. I didn’t want to live anymore,” she said solemnly.

As she described it, her negative thoughts can be induced by one simple occurrence, such as a stranger giving her a dirty look. It can lead her to racing thoughts centered on self-doubt, self-pity, and self-loathing, which are common with bipolar II and mixed bipolar disorder.

“Mixed episodes are pretty hell-ish,” she said. “You feel extremely depressed, but your mind is extremely active. It’s like your mind is throwing rocks at you and you don’t have the power to stop it.”

In other cases, the validity of a mild form of bipolar I diagnosis can be doubted by the patient, who may actually agree with people, such as Santamaria, that only have an outside perspective on the mood disorder.

“The psychologist I went to said I had bipolar II disorder. I just thought, ‘are you kidding me?’ I knew I was depressed, but bipolar?” Shelby Klein, 19, said. “I don’t really believe I am. I was going through a hard time because something I’d rather not say happened to me when I was 15. But I feel good now.”

This shows the problem with the widening of the bipolar spectrum. Although this means that more people will have the chance to be relieved by their otherwise consuming, negative instability, it also leaves the room for misdiagnosis. Klein, for example, claims to be fine now. Although bipolar disorder can be triggered by trauma, it is a life-long illness and doesn’t just go away.

It could be that she was not in a good place in her life and that it was just a phase, as is the case with everybody. People have their good years and their bad years. A reason why she may have been over-diagnosed is because now that she has moved past her traumatic experience, is in a healthy, loving relationship, and has plenty of friends who support her, she feels good, even without her medication. She said she still has her moments but it’s something she can control.

This can be compared to Vasilev’s circumstance. She is the leader of a support group that focuses on bringing people with mental disorders together to help them live their life fully, to realize that they are not alone and that they don’t have to handle the hardships by themselves. She also works as a model, has a naturally peppy personality, and speaks optimistically about her future and continuing recovery since her hospitalization.

“I was blessed with a loving family who could take care of me financially when I was in the hospital and someone who loves me enough to kiss me even when I’m crying and throwing things at him for no reason,” she said.

Despite the positivity in her life, she still has her irrational, uncontrollable moments and depends on her medication to keep her from going over the edge again.

Psychiatrists and psychologists face the challenge in being able to differentiate between a patient going through a difficult time and a patient with a mental illness. This gray area that derives from the bipolar disorder spectrum is a significant contributor to the drastic rise in people diagnosed with it in the United States, particularly in the adolescent and young adult age group.

Adults have also had significant growth over the past few decades but it was the youth group that saw a 40-fold increase in just a decade between 1993 and 2004, which was released in 2007 in the Archives of General Psychiatry.

This discovery was still being referenced as recently as 2011 in several articles and blog posts including “Children with Bipolar Disorder? Really?” by Thomas Plante published on the Psychology Today website, “The Story Behind the Rise in Bipolar Diagnoses” by psychiatrist John M. Grohl on the mental health social network Psych Central, and others. This shows the prevalence of such a discovery and the immense impact it has made on the psychiatric community.

Now, there are 5.7 million Americans, about 2.6 percent of the population 18 and over currently diagnosed with the disorder, according to the Depression and Bipolar Support Alliance, WebMD, and the National Institute of Mental Health. Many of the adults in this age group were in the youth category when the 40-fold increase occurred and the youth of today continue to be part of the progressing bipolar spectrum.

“The field used to think that children and adolescents could not experience bipolar disorder, but we now know that they can,” Jensen-Doss said. “So, there has been an increased detection of bipolar disorder among children and adolescents who would have gone undiagnosed in the past.”

Also, parents that are desperate for answers as to why their child is upset stimulate the increased diagnosis among youth. This was the case with Klein. It wasn’t her choice to go see a psychologist. Instead, it was her mother who was concerned with her change in behavior and since Klein didn’t feel comfortable sharing her traumatic experience with her, she searched for another source to provide reasoning.

Psychiatrists and psychologists have the means to help a person if they or a worried parent express that they are in mental and emotional distress. Therefore, it could come off as heartless for a psychiatrist to undermine a concern by saying that it’s just a phase.

The truth is it is difficult to diagnose a mood disorder since it is based on the trained mental health professional asking questions and the patient answering.

This means that the accuracy of the diagnosis relies on the willingness of the patient to fully express how they are feeling and how the psychiatrist or psychologist interprets it to compare to the symptoms of the disorder defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).